Metabolic and Bariatric Surgery Outcomes in African American Patients: a Single Institution Experience.

BACKGROUND: The incidence of obesity in African Americans (AAs) is higher than in non-AA in the USA. Previous studies using large national databases report that AA patients have worse outcomes than non-AA patients. OBJECTIVES: To assess perioperative outcomes among AA patients after MBS at a center of excellence (COE) that serves a large, diverse patient population. SETTING: University Hospital METHODS: A retrospective analysis was performed on patients undergoing MBS between 2010 and 2020 at our two accredited MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) COEs where the AA population makes up over 35% of the population. Preoperative variables were compared using unpaired t-test or chi-squared test where appropriate. Thirty-day outcomes were compared following propensity score matching (exact algorithm) of demographics and comorbidities. RESULTS: Overall, 5742 patients (AA = 2058, 36%) had Roux-en-Y gastric bypass (AA = 1028, 26%) or sleeve gastrectomy (AA = 1030, 27%). AA patients were more often female (90.2% vs. 80.2%, p < 0.001) and had higher rates of hypertension (56.3% vs. 47.8%, p < 0.001), while non-AA patients had higher rates of hyperlipidemia (27.3% vs. 20.7%, p < 0.001) and obstructive sleep apnea (41.2% vs. 37.1%, p = 0.0024). Matched data showed that AA patients had higher rates of pulmonary embolism (PE) (0.3% vs. 0.1%, p = 0.020) and more emergency department visits (7.0% vs. 5.1%, p = 0.012) but no differences in mortality, readmission, reintervention, or reoperation rates. CONCLUSIONS: In a diverse area, AA patients who underwent MBS had similar perioperative outcomes compared to non-AA patients except that they experienced higher rates of PE. They also experienced higher rates of emergency department visits but had similar readmission rates.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2.

INTRODUCTION: Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m2. We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI 335 kg/m2 and < 50 kg/m2) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie. METHODS: A retrospective review was performed on patients with a BMI < 50 mg/k2 who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate. RESULTS: Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m2 and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency. CONCLUSION: BPD-DS may be considered in patients with BMI < 50 kg/m2 with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

The role of total alimentary limb length in Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an established surgical treatment for obesity. Variations in limb length during RYGB procedures have been investigated for optimizing weight loss while minimizing nutritional deficiencies. The role of the total alimentary limb length (TALL; Roux limb plus common channel [CC]), however, is poorly defined. OBJECTIVE: Compare TALL in RYGB procedures for weight loss outcomes and malnutrition. SETTING: Systematic review. METHODS: Ovid Medline and PubMed databases were searched for entries between 1993 and 2020. Search terms included "gastric bypass" and "TALL." Two independent reviewers screened the results. RESULTS: A total of 21 studies measured TALL in RYGB. Of these, 4 of 6 reported a relationship between TALL and weight loss. Additionally, 11 studies reported that when TALL was ≤400 cm and CC <200 cm, 3.4% to 63.6% of patients required limb lengthening for protein malnutrition. CONCLUSIONS: The majority of studies on RYGB do not report TALL length. There is some evidence that weight loss is affected by shortening TALL, while a TALL ≤400 cm with CC<200 should be avoided due to severe protein malnutrition. More studies on the effect of TALL are needed.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

INTRODUCTION: For patients with super obesity (BMI > 50 kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. MATERIALS AND METHODS: The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. RESULTS: There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). CONCLUSIONS: Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Adenocarcinoma arising at ileostomy sites: Two cases and a review of the literature.

Total colectomy with ileostomy placement is a treatment for patients with inflammatory bowel disease or familial adenomatous polyposis (FAP). A rare and late complication of this treatment is carcinoma arising at the ileostomy site. We describe two such cases: a 78-year-old male 30 years after subtotal colectomy and ileostomy for FAP, and an 85-year-old male 50 years after colectomy and ileostomy for ulcerative colitis. The long latency period between creation of the ileostomies and development of carcinoma suggests a chronic metaplasia due to an irritating/inflammatory causative factor. Surgical excision of the mass and relocation of the stoma is the mainstay of therapy, with possible benefits from adjuvant chemotherapy. Newly developed lesions at stoma sites should be biopsied to rule out the possibility of this rare ileostomy complication.